3 Clinical psychopharmacology3.4 Therapeutics
3.4.1.1 Establishing goals of treatment
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Written by Resident Doctor Committee · Published
Starting point
A treatment goal states what should improve, by how much, by when, and when treatment will be reviewed.
Record the syndrome, phase, duration, severity and functional impact, since similar symptoms need different treatment in mania, delirium or residual illness.
Deal first with immediate risks: suicide, violence, catatonia, withdrawal and inability to eat or drink.
Assess physical illness, substance use and medication effects, and record a baseline.
Types of outcome
Term | Meaning | Implication |
|---|---|---|
Response | Clinically important improvement, conventionally 50% on a rating scale | Substantial symptoms remain |
Remission | Symptoms below threshold and syndrome absent | Aim of acute treatment |
Recovery | Sustained remission with function restored | Aim of the whole plan |
Relapse prevention | Stops the current episode returning | Job of continuation treatment |
Recurrence prevention | Stops a new episode after recovery | Job of maintenance treatment |
Time horizons
Horizon | Goal | Dose and duration |
|---|---|---|
Short term | Distress, risk and the acute syndrome | Review timed to harm as well as benefit |
Continuation | Consolidate remission and prevent relapse | The dose that produced response, for 6 to 12 months in depression |
Maintenance | Prevent recurrence | Judged on recurrence risk, cumulative drug harm and patient wishes |
Review antidepressants early, generally within two weeks, and sooner when suicide risk or age demands it.
Function and patient priorities
Ask what matters to the patient, such as parenting or study, since better symptoms may not be worth intolerable sedation or sexual effects.
Set observable, achievable goals, such as attending one class a week, without moral judgement about disability or circumstances.
If capacity is impaired, use the applicable legal framework while still involving the person and their known preferences.
Measuring and explaining
Symptoms, functioning and harms each need their own measure, taken with consistent method and timing, and a named person reviews results and escalates.
Explain that adverse effects may come before benefit, symptom control is not cure, and trial averages do not predict one person's response.
Describe risk in absolute numbers, with the uncertainty.
Decision points
Agree in advance an adequate dose and duration, and the benefit needed to continue.
With a poor response, review dose, duration, adherence, diagnosis, interactions and comorbidity before calling the treatment a failure.
Partial response may support optimisation, whereas no benefit may favour switching.
Define urgent adverse effects in advance, such as severe rash, toxicity or activation.
Before stopping, plan tapering, follow-up and the response to relapse.
Every continuing medicine needs a current indication, monitoring, a review date and a recorded reason for continuing.